Practice exam feedback 2019 2 Question 3 Question

Practice exam feedback 2019. 2 Question 3

Question 3 • • • 9 marks High level knowledge required for good answers Referenced Dunn and Therapeutic guidelines “Pass” score 6/9 Pass rate 27. 5% • Many borderline candidates • If everyone had scored an additional 1 mark, pass rate would be 57. 5% • Suggest you go and have a look at Therapeutic guidelines as many candidates were close but lacked detail

a) State 1 Pro and 1 Con for use of CURB 65 • Referenced to Dunn • Pro’s • Validated • Easy to use • Can be modified to removed urea (CRB-65) • Cons • Doesn't include O 2 or co-morbidities • Overestimates severity in elderly • Underestimates severity in young

Common errors • Writing more than one answer in each section • Not understanding what a Pro is • Writing “a risk stratification tool that assists in determining mortality risk and therefore aids decisions on treatment location (admit vs discharge)” • This is what the tool is, not why it is good • Misusing the terms Sensitivity/Specificity • These terms are not appropriate here • Getting confused with other scoring systems eg SMART COP

b) List 4 components • Needed any 4 of these • Confusion • Urea >7 • Respiratory rate >30 • Blood pressure: systolic <90 diastolic <60 • Age >65

Common errors • Having wrong components eg O 2 sats • Not including the reference range or having the wrong number eg Urea>20 • Remember this is a high level knowledge question, as such reference range is required • Writing 5 answers – only the first 4 considered.

c) According to Therapeutic Guidelines, prescribe antibiotics for CURB 65 score zero • Monotherapy • Amoxycillin 1 g tds orally, for 5 -7 days • Monotherapy (if atypical suspected) • Doxycycline 100 mg bd, for 5 -7 days • Not required for answer - Combination therapy (if follow up cannot be confirmed or failure of treatment at 48 hrs) • Amoxycillin 1 g tds plus doxycycline 100 mg bd

Common errors • Wrong dose amoxycillin • Many wrote 500 mg tds • Wrong drug • Augmentin duo forte is not recommended treatment • No duration of therapy • If a question asks you to “prescribe” you need to write the same detail that would go on a prescription or medication chart

d) Antibiotic choice for CF patient with lower Resp tract infection • Challenging question as there is no specific recommended drug • It depends upon the stage of life the patient is, and whether they have been colonized with a resistant organism • The most common organism is Pseudomonas, but can have a variety, and abx choice should be targeted to previous sputum results (no one actually mentioned this in their answer) • Inhaled antibiotics are often useful in this group, only one person mentioned Tobramycin (did not expect a dose for this drug given how infrequently this is prescribed by ED Physicians • I expected you to at least cover Pseudomonas for a patient at high risk of severe infection

Pseudomonas (general treatment, not specific to CF) • Ceftazidime 2 g tds • Or • Piperacillin/tazobactam 4. 5 g 6 hourly • Plus for those patients with severe pneumonia or bacteraemia, either of the above with either Gentamicin 3 -5 mg/kg or Ciprofloxacin 400 mg tds IV

Common errors • Not recognizing that this patient probably needs more aggressive treatment given background • Commencing oral cipro only (probably needs parenteral treatment) • Using monotherapy only (probably needs to have Gent/cipro as second agent in this patient) • Use of brand name – Tazocin (though this could be argued and some of the other examiners may disagree on this point). Most people charted Pip/Taz as a tds regime, not qid as per therapeutic guidleines • Use of ceftriaxone/azithromycin, or meropenum (this last one may be used based on sensitivities of sputum cultures, but should be avoided if possible to prevent further resistance) • Wrong doses or no doses

Good luck!